Phillips-Edison ARC Grocery Center REIT II, Inc. SUBSCRIPTION AGREEMENT INSTRUCTION PAGE

Size: px
Start display at page:

Download "Phillips-Edison ARC Grocery Center REIT II, Inc. SUBSCRIPTION AGREEMENT INSTRUCTION PAGE"

Transcription

1 Phillips-Edison ARC Grocery Center REIT II, Inc. SUBSCRIPTION AGREEMENT INSTRUCTION PAGE (For optional electronic delivery, see page 3) In no event may a subscription of shares be accepted until at least five business days after the date the subscriber receives the final prospectus. You will receive a confirmation of your purchase. PROCEDURES: Your broker-dealer or registered investment advisor should MAIL properly completed and executed ORIGINAL documents, along with your check payable to Phillips Edison ARC Grocery Center REIT II, Inc. to the following address (except that Pennsylvania investors should continue to follow the instructions below until $100,000,000 has been raised. See Prospectus Summary Terms of the Offering in the prospectus): Phillips Edison ARC Grocery Center REIT II, Inc. c/o DST Systems, Inc. 430 W. 7th Street Kansas City, Missouri Phone: (866) Fax: (877) For investors in Pennsylvania: Until we have raised the minimum offering amount, your broker-dealer or registered investment advisor should MAIL properly completed and executed ORIGINAL documents, along with your check payable to UMB Bank, N.A., Escrow Agent for Phillips Edison ARC Grocery Center REIT II, Inc. to Realty Capital Securities, LLC at the following address: Phillips Edison ARC Grocery Center REIT II, Inc. c/o Realty Capital Securities, LLC One Beacon Street Boston, MA Phone (877) Fax (857) *For IRA Accounts, mail investor signed documents to the IRA Custodian for signatures. Realty Capital Securities, LLC will then forward your check to our escrow agent, UMB Bank, N.A. If you have any questions, please call your registered representative or Realty Capital Securities, LLC at Should you have any questions or concerns and require customer service to handle your request or inquiry, please contact our transfer agent at: American National Stock Transfer, LLC 405 Park Avenue, 12th Floor New York, NY Phone: (877) Facsimile: (646) *For IRA Accounts, mail investor signed documents to the IRA Custodian for signatures. If you have any questions, please call your registered representative or Realty Capital Securities, LLC at Instructions to Subscribers Section 1: Indicate investment amount (Make all checks payable as described above.) Section 2: Choose type of ownership Non-Custodial Ownership Accounts with more than one owner must have ALL PARTIES SIGN where indicated on page 5. Be sure to attach copies of all plan documents for Pension Plans, Trust or Corporate Partnerships required in section 2. Custodial Ownership For New IRA/Qualified Plan Accounts, please complete the form/application provided by your custodian of choice in addition to this subscription document and forward to the custodian for processing. For existing IRA Accounts and other Custodial Accounts, information must be completed BY THE CUSTODIAN. Have all documents signed by the appropriate officers as indicated in the Corporate Resolution (which are also to be included). Section 3: All names, addresses, Dates of Birth, Social Security or Tax I.D. numbers of all investors or Trustees Section 4: Choose Distribution Allocation option Section 5: To be signed and completed by your Financial Advisor (be sure to include CRD number for FA and BD Firm and the Branch Manager s signature) Section 6: Have ALL owners initial and sign where indicated on Page 5 Section 7: All investors must complete and sign the substitute W9

2 Phillips Edison-ARC Grocery Center REIT II, Inc. SUBSCRIPTION AGREEMENT AN INVESTMENT IN THE OFFERING DESCRIBED HEREIN CANNOT BE COMPLETED UNTIL AT LEAST FIVE (5) BUSINESS DAYS AFTER THE DATE THE INVESTOR RECEIVED THE FINAL PROSPECTUS FOR THE OFFERING. SUBSCRIPTIONS WILL BE EFFECTIVE ONLY UPON OUR ACCEPTANCE, AND WE RESERVE THE RIGHT TO REJECT ANY SUBSCRIPTION IN WHOLE OR IN PART. IF REJECTED, ALL FUNDS SHALL BE RETURNED TO SUBSCRIBERS WITHOUT INTEREST AND WITHOUT DEDUCTION FOR ANY EXPENSES WITHIN TEN BUSINESS DAYS FROM THE DATE THE SUBSCRIPTION IS REJECTED. INVESTORS WILL RECEIVE A CONFIRMATION OF THEIR PURCHASE. IN ORDER TO EXECUTE THIS SUBSCRIPTION AGREEMENT, YOU AND THE CO-OWNER (AS APPLICABLE) MUST COMPLETE SECTION 6A OF THIS AGREEMENT. IF YOU HAVE ANY QUESTIONS, PLEASE CALL YOUR REGISTERED REPRESENTATIVE OR REALTY CAPITAL SECURITIES, LLC (MEMBER FINRA/SIPC) AT Please Investment Investment Amount indicate the offering you wish to invest in and whether this purchase is an initial investment or an additional investment. Phillips Edison-ARC Grocery Center REIT II, Inc. ( Grocery Center REIT II ) State in which sale was made: Initial Investment Additional Investment: Acct# $ $2,500 minimum investment $100 increments for additional investments Net of Commission Purchase ( NOCP ): Check this box if you are eligible for a NOCP. NOCPs are available to registered associates and other employees of soliciting broker/dealers, the above referenced REITs and their affiliates, participants in a wrap account or commission replacement account with approval for a discount by the broker/dealer, RIA, bank trust account, etc. Representative will not receive selling commission. Refer to prospectus for details. Payment Method: Please indicate the method of payment below. Check Enclosed Subscription amount wired Check/funding being sent by other third party Payment Instructions: Please follow the instructions outlined below. For custodial held accounts, such as IRAs and other qualified plans: Checks should be made payable to the custodian and sent, with a completed copy of the Subscription Agreement, directly to the custodian who will forward them to the applicable address. For all other investments: For Grocery Center REIT II make checks payable to (except investors in PA): Phillips Edison Grocery Center REIT II, Inc. For Grocery Center REIT II investors in PA, make checks payable to: UMB Bank, NA, Escrow Agents for Phillips Edison-ARC Grocery Center REIT II, Inc. Note: Investment subject to suitability standards, see the corresponding Prospectus for details. 2 OWNERSHIP IMPORTANT: Please choose one option, either within the Non-Custodial Ownership column, or within the Custodial Ownership column. 2a. Non-Custodial Ownership (Non-Qualified) Individual One signature required & initial. Joint Tenants with Right of Survivorship All parties must sign & initial. Tenants in Common All parties must sign & initial. Company or Corporation or Partnership Authorized signature required. Include Corporate Resolution or Partnership Agreement, as applicable. Uniform Gift/Transfer to Minors Act (UGMA/UTMA) Owner and custodian signature required. State of Custodian for Estate Personal representative signature required. Name of Executor: Include a copy of the court appointment. Qualified Pension or Profit Sharing Plan* Trustee or custodian signature required. Include plan documents. Name of Trustee: Trust Trustee(s) signature(s) and copy of trust document or trust certificate required. Transfer on Death (1) Must complete separate Transfer on Death Registration Form. Other (Specify) Include title and signature pages. 2b. Custodial Ownership (Qualified) Traditional IRA* One signature required. Roll-Over IRA* One signature required. Roth IRA* One signature required. KEOGH Plan* One signature required. Simplified Employee Pension/Trust (S.E.P.)* Qualified Pension or Profit Sharing Plan* Owner and custodian signature required. Other (Specify) ** Investors who are plan participants under a registered IRA, Keogh, Qualified Pension Plan or Qualified Profit Sharing Plan program may be eligible to purchase such investment through such accounts. No representations are made, and the offeror disclaims any responsibility or liability to the plan custodian, plan administrators, plan participants, investors, or beneficiaries thereof as to the tax ramifications of such investment, the suitability or eligibility of such investment under the respective plan, or that such Investment comports with ERISA, Internal Revenue Service or other governmental rules and regulations pertaining to such plan investments and rights thereunder. A separate private investment form or similar documentation from the Plan Custodian/ Administrator and plan participants/investors is required for investment through these types of accounts. (1) Investors who qualify may elect Transfer on Death (TOD) registration for such investment account. TOD registration is designed to give an owner/investor of securities the option of a nonprobate transfer at death of the assets held in the account by designating proposed beneficiary(ies) to receive the account assets upon the owner/investor s death. TOD registration is available only for owner(s)/ investor(s) who is (i) a natural person or (ii) two natural persons holding the account as Tenants by the Entirety or (iii) two or more natural persons holding the account as Joint Tenants with Right of Survivorship or (iv) a married couple holding the account as community property with right of survivorship. The following forms of ownership are ineligible for TOD registration: Tenants in Common, community property without survivorship, non-natural account owners (i.e., entities such as corporations, trusts or partnerships), and investors who are not residents of a state that has adopted the Uniform Transfer on Death Security Registration Act.

3 3 IMPORTANT: Send all paperwork directly to the custodian. Note: This section is only for accounts specified in Section 2b and not for Custodial Accounts for Minors. Custodial Ownership (Must be completed by Custodian/Trustee for accounts identified in Section 2b) Name of Trust or Business Entity (Does not apply to IRA accounts) Name of Custodian or Trustee Mailing Address Business Phone 4 IMPORTANT: Investor Information is required. Note: Please provide all necessary corporate documents, partnership agreement, or trust powers (specified in Section 2) to establish authority to act. Custodian/Trust/Business Entity Tax ID# Account # Name of Custodian or Other Administrator Investor Information Mr. Mrs. Ms. Other Name of Account Owner Date of Birth Social Security Number or Taxpayer ID # Legal Address (No P.O. Boxes) Citizenship: Please indicate Citizenship Status (Required) U.S. Citizen Resident Alien Non-Resident Alien* Employee, Affiliate or Board Member NOTE: Any and all U.S. Taxpayers are required to complete W-9 form in Section 6b * If non-resident alien, investor must submit the appropriate W-8 form (W-8BEN, W-8ECI, W-8EXP or W-8IMY) in order to make an investment. (Again, if a foreign national who is, in fact, a U.S taxpayer, complete W-9 form.) Employer: RETIRED Mr. Mrs. Ms. Other Name of Joint Account Owner or Minor Entity Name Date of Birth Social Security Number or Taxpayer ID# If Non-U.S. Citizen, specify Country of Citizenship Mailing Address (if different than legal address) Home Phone Business Phone Government ID: (Foreign Citizens only) Identification documents must have a reference number and photo. Please attach a photocopy. Place of Birth: City State/Province Country Immigration Status: Permanent resident Non-permanent resident Non-resident Check which type of document you are providing: US Driver's License INS Permanent resident alien card Passport with U.S. Visa Employment Authorization Document Passport without U.S. Visa Bank Name (required): Account No. (required): Foreign national identity documents Bank Name (required): Phone No. (required): Number for the document checked above and country of issuance: CALIFORNIA INVESTORS: ALL CERTIFICATES REPRESENTING SHARES WHICH ARE SOLD IN THE STATE OF CALIFORNIA WILL BEAR THE FOLLOWING LEGEND CONDITIONS: IT IS UNLAWFUL TO CONSUMMATE A SALE OR TRANSFER OF THIS SECURITY OR ANY INTEREST THEREIN, OR TO RECEIVE ANY CONSIDERATION THEREFOR, WITHOUT THE PRIOR WRITTEN CONSENT OF THE COMMISSIONER OF CORPORATIONS FOR THE STATE OF CALIFORNIA, EXCEPT AS PERMITTED IN THE COMMISSIONER S RULES. Any subscriber seeking to purchase shares pursuant to a discount offered by us must submit such request in writing and set forth the basis for the request. Any such request will be subject to our verification.

4 5 Complete this section to enroll in the Distribution Reinvestment Plan or to elect how you wish to receive your distributions. 1 Note: Qualified accounts may not direct distributions without the custodian s approval. Please also note that all custodial account distributions not reinvested pursuant to the distribution reinvestment plan will be directed to the custodian. Distributions PHILLIPS EDISON-ARC GROCERY CENTER REIT II, INC. I hereby subscribe for Shares of Phillips Edison-ARC Grocery Center REIT II, Inc. and elect the distribution option indicated. Reinvest/Distribution Reinvestment Plan 2,3 Investor elects to participate in the Distribution Reinvestment Plan described in the Prospectus and reinvests the entire cash distribution. Mail Check to the address of record Send to Custodial Account listed in Section 3 Cash/Direct Deposit 4 Send check/direct deposit to third party financial institution in Section 5a below. (Non-Custodian Investors only) Automatic Purchase Plan: Check this box if you wish to participate in the Automatic Purchase Plan ( APP ). A separate form is required to be completed to participate in APP. * * Alabama, Kansas, Nebraska and Ohio investors cannot participate in the Automatic Purchase Plan. 1 Distributions may be funded from borrowings, offering proceeds, or proceeds from the sale of assets, which may constitute a return of capital and significantly reduce the amount of capital available for investment by Phillips Edison-ARC Grocery Center REIT II, Inc. Any capital returned to investors through distributions will be returned after certain fees and expenses are paid to the sponsor of this offering or its affiliates. 2 Alabama and Ohio investors cannot participate in the Distribution Reinvestment Plan feature that reinvests distributions into subsequent affiliated programs. 3 We request that an investor who elects to have distributions reinvested notify the applicable program and the broker-dealer in writing if at any time during his or her participation in the distribution reinvestment plan, there is any material change in the stockholder s financial condition or inaccuracy of any representation under the subscription agreement for such stockholder s initial purchase of our shares. 4 I authorize Phillips Edison-ARC Grocery Center REIT II, Inc., or its agent, American National Stock Transfer, LLC, by or through a third party provider, (collectively referred to as Issuer ) to deposit my distribution/dividend to my checking or savings account. This authority will remain in force until I notify the Issuer in writing to cancel it. If the Issuer deposits funds erroneously into my account, they are authorized to debit my account for an amount not to exceed the amount of the erroneous deposit. The above services cannot be established without a pre-printed voided check. For electronic funds transfers, signatures of bank account owners are required exactly as they appear on the bank records. If the registration at the bank differs from that on this Subscription Agreement, all parties must sign below. Investors ability to sell shares pursuant to the Share Repurchase Program is subject to numerous restrictions. The Share Repurchase Program may be suspended or terminated at ay time and individual requests for redemption may not be honored. Investors may not be able to sell their shares. 5a Please complete this section if you should wish to direct distributions (non-custodial accounts) to the registered owner s checking or savings account or to a party other than the registered owner. Name of Third Party Financial Institution Mailing Address Account # Bank's ABA/Routing # Checking Account (must enclose voided check) Savings Account (subject to bank verification) ELECTRONIC DELIVERY ELECTION Electronic Delivery of stockholder communication is available and if you would prefer to receive such communications and statements electronically, please affirmatively elect to do so by checking the offering for which you elect to receive the electronic delivery of stockholder communications and statement notifications, and signing below where indicated: Phillips Edison-ARC Grocery Center REIT II, Inc. We encourage you to reduce printing and mailing costs and to conserve natural resources by electing to receive electronic delivery of stockholder communications and statement notifications. By consenting below to electronically receive stockholder communications, including your account-specific information, you authorize said offering(s) to either (i) stockholder communications to you directly or (ii) make them available on each offering s respective Web site and notify you by when such documents are available and how to access the documents. You will not receive paper copies of these electronic materials unless specifically requested, the delivery of electronic materials is prohibited or we, in our sole discretion, elect to send paper copies of the materials. Sign below if you consent to the electronic delivery of documents including annual reports, proxy materials, and any other documents that may be required to be delivered under federal or state securities laws as well as account-specific information such as quarterly account statements or tax information. Your consent will be effective until you revoke it. In addition, by consenting to electronic access, you will be responsible for your customary Internet Service Provider charges in connection with access to these materials. address in the section below is required. Please carefully read the following representations before consenting to receive documents electronically. By signing this box and consenting to receive documents electronically, you represent the following: (a) I acknowledge that access to both Internet and the World Wide Web is required in order to access documents electronically. I may receive by notification the availability of a document in electronic format. The notification will contain a web address (or hyperlink) where the document can be found. By entering this address into my web browser, I can view, download and print the document from my computer. I acknowledge that there may be costs associated with the electronic access, such as usage charges from my Internet provider and telephone provider, and that these costs are my responsibility. (b) I acknowledge that documents distributed electronically may be provided in Adobe s Portable Document Format (PDF). The Adobe Reader software is required to view documents in PDF format. The Reader software is available free of charge from Adobe s web site at The Reader software must be correctly installed on my system before I will be able to view documents in PDF format. Electronic delivery also involves risks related to system or network outage that could impair my timely receipt of or access to stockholder communications. (c) I acknowledge that I may receive at no cost from Phillips Edison-ARC Grocery Center REIT II, Inc. a paper copy of any documents delivered electronically by calling Realty Capital Securities, LLC at from 9:00 am to 5:00 pm EST Monday-Friday. (d) I acknowledge that if the notification is returned to Phillips Edison-ARC Grocery Center REIT II, Inc. as undeliverable, a letter will be mailed to me with instructions on how to update my address to begin receiving communication via electronic delivery. I further understand that if Phillips Edison-ARC Grocery Center REIT II, Inc. is unable to obtain a valid address for me, Phillips Edison-ARC Grocery Center REIT II, Inc. will resume sending a paper copy of its filings by U.S. mail to my address of record. (e) I acknowledge that my consent may be updated or cancelled, including any updates in address to which documents are delivered, at any time by calling Realty Capital Securities, LLC at from 9:00 am to 5:00 pm EST Monday-Friday. Owner Signature Date (mm/dd/yyyy) Co-Owner Signature (if applicable) Date (mm/dd/yyyy) Joint Accounts: If your Social Security number is the primary number on a joint account and you opt-in to electronic delivery, each consenting stockholder must have access to the account provided. My address is Your address will be held in confidence and used only for matters relating to your investments.

5 6 IMPORTANT: Please carefully read and separately initial each of the representations. Except in the case of fiduciary accounts, you may not grant any person a power of attorney to make such representations on your behalf. Subscriber Acknowledgements & Signatures The undersigned (or in the case of fiduciary accounts, the person authorized to sign on each subscriber s behalf ) further acknowledges and/or represents the following: (you must initial ALL appropriate representations below) Owner Co-Owner Represents that I (we) either: (i) have a net worth (excluding home, home furnishings and automobiles) of at least $70,000 and gross income of at least $70,000; or (ii) have a net worth (excluding home, home furnishings and automobiles) of at least $250,000 or such higher suitability as may be required by certain states and set forth in the Investor Suitability Standards section of the applicable Prospectus. In the case of sales to fiduciary accounts, suitability standards must be met by the beneficiary, the fiduciary account or by the donor or grantor who directly or indirectly supplies the funds for the purchase of the Shares. I/we acknowledge receipt of the final Prospectus of Grocery Center REIT II, not less than five (5) business days prior to the signing of this Subscription Agreement. I/we am/are purchasing shares for my/our own account. I/we acknowledge that shares are not liquid. If an affiliate of Grocery Center REIT II, I/we represent that the shares are being purchased for investment purposes only and not for immediate resale. Kansas residents only: In addition to the suitability requirements described above, it is recommended that investors should invest no more than 10% of their liquid net worth, in the aggregate in Grocery Center REIT II shares and securities of other real estate investment trusts. Liquid net worth is defined as that portion of net worth (total assets minus total liabilities) that is comprised of cash, cash equivalents and readily marketable securities. Alabama residents only: In addition to the suitability standards above, shares will only be sold to Alabama residents that represent that he or she has a liquid net worth of at least 10 times the amount of his or her investment in Grocery Center REIT II and its affiliates. Nebraska residents only: Investors must have either (a) a net worth of $350,000 or (b) a net worth of $100,000 and an annual income of $70,000. The investor s maximum investment in Grocery Center REIT II and its affiliates should not exceed 10% of his or her net worth. Kentucky residents only: Investors must have either (a) a minimum net worth of $250,000 or (b) a minimum gross annual income of at least $70,000 and a net worth of at least $70,000, with the amount invested in the Grocery Center REIT II offering not to exceed 10% of the Kentucky investor s liquid net worth. Massachusetts, Ohio, Oregon and New Mexico residents only: Investors must have either (a) a minimum net worth of at least $250,000 or (b) an annual gross income of at least $70,000 and a net worth of at least $70,000. The investor s maximum investment in Grocery Center REIT II and its affiliates cannot exceed 10% of the Oregon resident s net worth. It shall be unsuitable for a Massachusetts, New Mexico or Ohio investor s aggregate investment in shares of Grocery Center REIT II, its affiliates and in other non-traded real estate investment programs to exceed ten percent (10%) of his, her or its liquid net worth. Liquid net worth shall be defined as that portion of net worth (total assets exclusive of primary residence, home furnishings and automobiles minus liabilities) that is comprised of cash, cash equivalents and readily marketable securities. Pennsylvania and Michigan residents only: A Pennsylvania or Michigan investor cannot invest more than 10% of his or her net worth in Grocery Center REIT II. Grocery Center REIT II will not accept subscriptions from Pennsylvania residents until it has raised $100,000,000 from other jurisdictions. Iowa residents only: The maximum investment allowable in Grocery Center REIT II and its affiliates is 10% of an Iowa investor s liquid net worth. Liquid net worth is defined as that portion of net worth (total assets minus total liabilities) that is comprised of cash, cash equivalents and readily marketable securities. New Jersey residents only: A New Jersey investor must have either (a) a minimum liquid net worth of $100,000 and a minimum annual income of $85,000 or (b) a minimum liquid net worth of $350,000. In addition, a New Jersey investor s total investment in the Grocery Center REIT II offering, shares of its affiliates and in other non-traded real estate investment trusts shall not exceed 10% of his or her liquid net worth. Liquid net worth is defined as that portion of net worth (total assets exclusive of home, home furnishings and automobiles, minus total liabilities) that is comprised of cash, cash equivalents and readily marketable securities. Tennessee residents only: A Tennessee resident s investment in Grocery Center REIT II shares must not exceed 10% of his or her liquid net worth (exclusive of home, home furnishings and automobiles). Missouri residents only: In addition to the suitability requirements described above, no more than ten percent (10%) of any one (1) Missouri investor s liquid net worth shall be invested in the Grocery Center REIT II securities registered with the Securities Division. California residents only: In addition to the general suitability requirements described above, California investors maximum investment in Grocery Center REIT II shares shall not exceed 10% of the investor s net worth (exclusive of home, home furnishings and automobile).

6 6 Continued Subscriber Acknowledgements & Signatures (Continued) (you must initial ALL appropriate representations below) Owner Co-Owner North Dakota residents only: North Dakota investors must represent that, in adddition to the general suitability standards listed above, they have a new worth of at least ten times their investment in the Grocery Center REIT II offering. Maine residents only: The Maine Office of Securities recommends that an investor s aggregate investment in the Grocery Center REIT II offering and similar direct participation investments not exceed 10% of the investor s liquid net worth. For this purpose, liquid net worth is defined as that portion of net worth that consists of cash, cash equivalents and readily marketable securities. WE INTEND TO ASSERT THE FOREGOING REPRESENTATION AS A DEFENSE IN ANY SUBSEQUENT LITIGATION WHERE SUCH ASSERTION WOULD BE RELEVANT. AS USED ABOVE, THE SINGULAR INCLUDES THE PLURAL IN ALL RESPECTS IF SHARES ARE BEING ACQUIRED BY MORE THAN ONE PERSON. THIS SUBSCRIPTION AGREEMENT AND ALL RIGHTS THEREUNDER SHALL BE GOVERNED BY, AND INTERPRETED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK WITHOUT GIVING EFFECT TO THE PRINCIPLES OF CONFLICT OF LAWS. BY EXECUTING THIS SUBSCRIPTION AGREEMENT, THE SUBSCRIBER HEREBY DECLARES THE INFORMATION SUPPLIED ABOVE IS TRUE AND CORRECT AND MAY BE RELIED UPON BY EACH ISSUER IN CONNECTION WITH THE SUBSCRIBER S INVESTMENT IN SUCH ISSUER. THE SUBSCRIBER DOES NOT WAIVE ANY RIGHTS IT MAY HAVE UNDER THE SECURITIES ACT OF 1933, THE SECURITIES EXCHANGE ACT OF 1934 OR ANY STATE SECURITIES LAW BY EXECUTING THIS SUBSCRIPTION AGREEMENT. A SALE OF SHARES MAY NOT BE COMPLETED UNTIL THE SUBSCRIBER HAS BEEN IN RECEIPT OF THE FINAL PROSPECTUS FOR THIS OFFERING (AT LEAST FIVE BUSINESS DAYS). THE SUBSCRIBER WILL NOT BE ADMITTED AS A SHAREHOLDER OF THE APPLICABLE ISSUER UNTIL THIS SUBSCRIPTION AGREEMENT HAS BEEN ACCEPTED BY SUCH ISSUER. SUCH ISSUER MAY REJECT ANY SUBSCRIPTION, IN WHOLE OR IN PART, IN ITS SOLE DISCRETION, SO LONG AS SUCH PARTIAL ACCEPTANCE OR REJECTION DOES NOT RESULT IN AN INVESTMENT OF LESS THAN THE MINIMUM AMOUNT SPECIFIED IN THE PROSPECTUS. SUBSCRIPTIONS WILL BE ACCEPTED OR REJECTED WITHIN 30 DAYS OF THEIR RECEIPT. EACH ISSUER WILL ACCEPT GROUPS OF SUBSCRIPTIONS ON AN ORDERLY BASIS NO LESS FREQUENTLY THAN MONTHLY, SUBJECT TO THE TERMS OF THE CURRENT PROSPECTUS. IF AN ISSUER REJECTS THE SUBSCRIBER S SUBSCRIPTION, THE PURCHASE PRICE WILL BE RETURNED TO THE SUBSCRIBER WITHIN 10 BUSINESS DAYS AFTER THE REJECTION OF THE SUBSCRIPTION. IF THE SUBSCRIBER S SUBSCRIPTION IS ACCEPTED, THE SUBSCRIBER WILL BE SENT A CONFIRMATION OF ITS PURCHASE AFTER THE SUBSCRIBER HAS BEEN ADMITTED AS A SHAREHOLDER. Subscriber Signature(s) 6 a IMPORTANT: The investor must go to Section 6b and complete the Substitute W-9 form in its entirety in order for the Subscription Agreement to be considered valid for review. * * Your ability to sell shares pursuant to the Share Repurchase Program is severely restricted. The Share Repurchase Program may be suspended or terminated at any time, and redemption requests may be rejected for any reason. You may not be able to sell your shares. SIGNATURE OF OWNER AND CO-OWNER (IN ORDER TO HAVE THIS AGREEMENT EXECUTED, THE INVESTOR(S) MUST SIGN THIS SECTION 6A) In addition, if the investor signing below is acquiring the shares through an IRA or will otherwise beneficially hold the shares through a Custodian or Trustee, the investor also authorizes the Investment Program(s) indicated in Section 1 to receive (on behalf of the investor) authorization for the investor to act as proxy for the Custodian or Trustee. This authorization coupled with the Custodian or Trustee authorization below is intended to permit the investor to vote his or her shares even though the investor is not the record holder of the shares. Signing Section 6B will not constitute an execution of this subscription agreement. Owner Signature Date (mm/dd/yyyy) Co-Owner Signature (if applicable) Date (mm/dd/yyyy) FOR AUTHORIZED REPRESENTATIVE OF CUSTODIAN USE ONLY Signature of Custodian(s) or Trustee(s): By signing this Subscription Agreement, the Custodian authorizes the investor to vote the number of shares of the Investment Program(s) indicated in Section 1 that are beneficially owned by the investor as reflected on the records of each said offering as of the applicable record date at any meeting of the shareholders of each said offering. This authorization shall remain in place until revoked in writing by the Custodian. The Investment Program(s) indicated in Section 1 are hereby authorized to notify the investor of his or her right to vote consistent with this authorization. Authorized Signature (Custodian or Trustee) Date (mm/dd/yyyy) SUBSTITUTE FORM W-9 (Form W-9 (Rev ) Certification 6b Substitute Form W-9 ALL U.S. Taxpayers Must Sign To prevent backup withholding on any payment made to a stockholder with respect to subscription proceeds held in escrow, the stockholder is generally required to provide current TIN (or the TIN of any other payee) and certain other information by completing the form below, certifying that the TIN provided on Substitute Form W-9 is correct (or that such investor is awaiting a TIN), that the investor is a U.S. person, and that the investor is not subject to backup withholding because (i) the investor is exempt from backup withholding, (ii) the investor has not been notified by the IRS that the investor is subject to backup withholding as a result of failure to report all interests or dividends or (iii) the IRS has notified the investor that the investor is no longer subject to backup withholding. If a TIN is not provided by the time any payment is made in connection with the proceeds held in escrow, 28% of all such payments will be withheld until a TIN is provided and if a TIN is not provided within 60 days, such withheld amounts will be paid over to the IRS. Exempt TIN. Check here if investor is an exempt payee. Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number, and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal

7 6b Substitute Form W-9 ALL U.S. Taxpayer Must Sign (Continued) Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (including a U.S. resident alien). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. Signature of Investor Print Name Date Signature of Joint Owner, if applicable Print Name Date 6b Guidelines for Certification of Taxpayer Identification Number ( TIN ) on Substitute Form W-9 What Number to Give the Requester. Social Security numbers ( SSN ) have nine digits separated by two hyphens: i.e., Employer identification numbers ( EIN ) have nine digits separated by only one hyphen: i.e., The table below will help determine the number to give the payer. All Section references are to the Internal Revenue Code of 1986, as amended. IRS means the Internal Revenue Service. For this type of account: 1. An individual s account 2. Two or more individuals (Joint account) 3. Custodian account of a minor (Uniform Gift to Minors Act) 4. (a) The usual revocable savings trust account (grantor also is trustee) (b) So-called trust account that is not a legal or valid trust under State law 5. Sole proprietorship or single-owner LLC For this type of account: 6. Sole proprietorship or single-owner LLC 7. A valid trust, estate, or pension trust 8. Corporate or LLC electing corporate status on Form Association, club, religious, charitable, educational, or other tax-exempt organization 10. Partnership or multi-member LLC 11. Account with the Department of Agriculture in the name of a public entity (such as a State or local government, school district or prison) that receives agricultural program payments 12. A broker or registered nominee Give the SSN of: The individual The actual owner of the account or, if combined funds, the first individual on the account (1) The minor (2) The grantor-trustee (1) The actual owner (1) The owner (3) Given the EIN of: The owner (3) The legal entity (4) The corporation The organization The partnership or LLC The public entity The broker or nominee (1) List first and circle the name of the person whose number you furnish. If only one person on a joint account has a SSN, that person s number must be furnished. (2) Circle the minor s name and furnish the minor s SSN. (3) You must show your individual name and you also may enter your business or DBA name on the second name line. You may use either your SSN or EIN (if you have one). If you are a sole proprietor, the IRS encourages you to use your SSN. (4) List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Note: If no name is circled when there is more than one name, the number will be considered to be that of the first name listed. Obtaining a Number If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security

8 6b Guidelines for Certification of Taxpayer Identification Number ( TIN ) on Substitute Form W-9 (Continued) Administration office or get this form online at You also may get this form by calling Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at and clicking on Employer ID Numbers under Related Topics. You can get Forms W-7 and SS-4 from the IRS by visiting or by calling TAX-FORM ( ). Payees Exempt from Backup Withholding Backup withholding is not required on any payments made to the following payees: An organization exempt from tax under Section 501(a), an individual retirement account ( IRA ), or a custodial account under Section 403(b)(7) if the account satisfies the requirements of Section 401(f )(2). The United States or any of its agencies or instrumentalities. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities. A foreign government or any of its political subdivisions, agencies or instrumentalities. An international organization or any of its agencies or instrumentalities. Other payees that may be exempt from backup withholding include: A corporation. A foreign central bank of issue. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States. A futures commission merchant registered with the Commodity Futures Trading Commission. A real estate investment trust. An entity registered at all times during the tax year under the Investment Company Act of A common trust fund operated by a bank under Section 584(a). A financial institution. A middleman known in the investment community as a nominee or custodian. A trust exempt from tax under Section 664 or described in Section Exempt payees should complete a Substitute Form W-9 to avoid possible erroneous backup withholding. Check the Exempt TIN box in the attached Substitute Form W-9, sign and date the form and return it to the payer. Foreign payees who are not subject to backup withholding should complete an appropriate Form W-8 and return it to the payer. Privacy Act Notice Section 6109 requires you to provide your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA, or Archer MSA or HSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. The IRS also may provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia and U.S. possessions to carry out their tax laws. The IRS also may disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to a payer. Certain penalties also may apply. Penalties Failure to Furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil Penalty for False Information With Respect to Withholding. If you make a false statement with no reasonable basis which results in no backup withholding, you are subject to a $500 penalty. Criminal Penalty for Falsifying Information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses taxpayer identification numbers in violation of Federal law, the payer may be subject to civil and criminal penalties. FOR ADDITIONAL INFORMATION CONTACT YOUR TAX CONSULTANT OR THE IRS.

9 7 RIA Submission: Check this box to indicate whether submission is made through a Registered Investment Advisor (RIA) in its capacity as the RIA and not in its capacity as a Registered Representative, if applicable, whose agreement with the subscriber includes a fixed or wrap fee feature for advisory and related brokerage services. If an owner or principal or any member of the RIA firm is a FINRA licensed Registered Representative affiliated with a broker-dealer, the transaction should be completed through that brokerdealer, not through the RIA. Special Alabama Undertaking Regarding APP: The Firm must check this box if the Automatic Purchase Plan ( APP ) box in Section 5 is checked and either the sale was made in Alabama or Alabama is the state designated as the investor s address. By checking the box at the beginning of this paragraph, the Firm covenants and agrees that: (1) the Firm will obtain updated suitability information from such investor on a quarterly basis; (2) this updated information will be provided in writing and signed by the investor; (3) if written suitability information is more than 90 days old, then the investor may not participate in the Automatic Purchase Plan until the information is updated; and (4) the updated information shall consist of the information that an investor is required to provide under Section 6 of this Subscription Agreement. For Non-Custodial 8 Accounts: Please mail a completed original Subscription Agreement along with a check and the appropriate documents outlined in Sections 1 and 2 of this agreement, to the appropriate address as outlined to the right. For Custodial Accounts: Please mail a completed original Subscription Agreement directly to the custodian, along with your check and the appropriate documents outlined in Sections 1 and 2 of this agreement. Financial Advisor, Registered Investment Advisor & Registered Representative The Financial Advisor, Registered Investment Advisor or the Authorized Representative (the Advisor ) must sign below to complete the order. The undersigned broker-dealer or Advisor warrants that it is a duly licensed broker-dealer (or noncommission based financial advisor) and may lawfully offer the Shares in the state designated as the investor s address or the state in which the sale is to be made, if different. The broker-dealer or Advisor warrants that he or she has (a) reasonable grounds to believe this investment is suitable for the investor as defined by Rule 2310 of the FINRA Rules, (b) informed the investor of all aspects of liquidity and marketability of this investment as required by Rule 2310 of the FINRA Rules, (c) delivered the Prospectus to the investor the requisite number of days prior to the date that the investor will deliver this Subscription Agreement to the issuer as specified under the laws of the investor s state of residence, (d) verified the identity of the investor through appropriate methods and will retain proof of such verification process as required by applicable law, and (e) verified that the investor and the registered owner do not appear on the Office of Foreign Assets Control list of foreign nations, organizations and individuals subject to economic and trade sanctions. Broker/Dealer or RIA Firm Address or P.O. Box Mailing Address Business Phone # (Required) Fax Phone # Address Registered Representative(s) or Advisor(s) [I.A.] Name(s) (Required) Representative # Registered Representative or Advisor [I.A.] Address or P.O. Box Business Phone # (Required) Fax Phone # Address If a Registered Associate of a FINRA member firm, I hereby certify that I hold a Series 7 or Series 62 FINRA license and I am registered in the following state in which this sale was completed. If a Registered Investment Advisor, I certify that I am properly licensed and I am registered in the following state in which this sale was completed. State (Required) Signature(s) of Registered Representative(s) or Advisor(s) (Required) Date Signature of Broker/Dealer or RIA (If Required by Broker/Dealer) Date For Regular Mail Phillips Edison Grocery Center REIT II, Inc. (except for Grocery Center REIT II investors in PA) c/o DST Systems, Inc. 430 W. 7th Street, Kansas City, MO For Overnight Deliveries State-Specific Mailing Address Differences for Grocery Center REIT II: For Grocery Center REIT II Investors in PA, mail to: Phillips Edison-ARC Grocery Center REIT II, Inc. c/o Realty Capital Services, LLC One Beacon Street, Boston, MA Phillips Edison Grocery Center REIT II, Inc. (except for Grocery Center REIT II investors in PA) c/o DST Systems, Inc. 430 W. 7th Street, Kansas City, MO Should you have any questions or concerns and require customer service to handle your request or inquiry, please contact our transfer agent at: American National Stock Transfer, LLC 405 Park Avenue, 12th Floor, New York, NY Phone (877) Fax (646) FOR COMPANY USE ONLY: Amount Date Check/Wire# Account # Registered Representative # Firm # Custodian ID# Transfer Agent Reviewer

Phillips Edison-ARC Shopping Center REIT Inc. Subscription Agreement

Phillips Edison-ARC Shopping Center REIT Inc. Subscription Agreement INSTRUCTIONS TO INVESTORS Phillips Edison-ARC Shopping Center REIT Inc. Subscription Agreement Subscription of shares may not be accepted until at least five business days after the date the subscriber

More information

TRANSFER AND ASSIGNMENT OF SHARES

TRANSFER AND ASSIGNMENT OF SHARES TRANSFER AND ASSIGNMENT OF SHARES Use this form to transfer or change the ownership of your account. Custodial held account changes must be authorized (signed) by the Custodian. 1. TRANSFER FROM THE FOLLOWING

More information

Method of delivery of the certificate(s) is at the option and risk of the owner thereof. See Instruction 1.

Method of delivery of the certificate(s) is at the option and risk of the owner thereof. See Instruction 1. LETTER OF TRANSMITTAL To accompany certificates of common stock, $1.00 par value per share, of Ameriana Bancorp. The undersigned represents that I (we) have full authority to surrender without restriction

More information

Missouri Lottery Winner Claim Form Official Missouri Lottery Claim Form

Missouri Lottery Winner Claim Form Official Missouri Lottery Claim Form [ STAPLE TICKET HERE ] Missouri Lottery Winner Claim Form Official Missouri Lottery Claim Form A B C PLEASE PRINT your name, address and phone number on the back of your ticket - YOU MUST SIGN YOUR TICKET.

More information

IRS FORM 1099 REPORTING REQUIREMENTS

IRS FORM 1099 REPORTING REQUIREMENTS IRS FORM 1099 REPORTING REQUIREMENTS The Internal Revenue Service (IRS) requires businesses (including not-for-profit organizations) to issue a Form 1099 to any individual or unincorporated business paid

More information

United Development Funding IV Account Transfer Form

United Development Funding IV Account Transfer Form United Development Funding United Development Funding Toll-Free 1-800-859-9338 SECTION 1 - TRANSFER FROM THE FOLLOWING ACCOUNT (Must complete for all transfers) UDF Account Number Name(s) on the Account

More information

STATE OF WYOMING WOLFS-109(a)

STATE OF WYOMING WOLFS-109(a) STATE OF WYOMING WOLFS-109(a) The State of Wyoming must have a properly completed form before payment will be made. STATE AGENCY INFORMATION Agency #, Agency Name, Contact Name, Title, Address; Phone #

More information

CONTRACTOR APPLICATION HOUSING REHABILITATION PROGRAM

CONTRACTOR APPLICATION HOUSING REHABILITATION PROGRAM CITY OF GALVESTON GRANTS & HOUSING DEPARTMENT P.O. Box 779 Galveston, Texas 77553 Office (409) 797 3820 Fax (409) 797 3888 CONTRACTOR APPLICATION HOUSING REHABILITATION PROGRAM CONTRACTOR APPLICATION HOUSING

More information

SUBSCRIPTION AGREEMENT AND POWER OF ATTORNEY REDWOOD MORTGAGE INVESTORS IX, LLC A DELAWARE LIMITED LIABILITY COMPANY

SUBSCRIPTION AGREEMENT AND POWER OF ATTORNEY REDWOOD MORTGAGE INVESTORS IX, LLC A DELAWARE LIMITED LIABILITY COMPANY EXHIBIT 4.1 SUBSCRIPTION AGREEMENT AND POWER OF ATTORNEY REDWOOD MORTGAGE INVESTORS IX, LLC A DELAWARE LIMITED LIABILITY COMPANY The undersigned hereby applies to purchase units in REDWOOD MORTGAGE INVESTORS

More information

UNPAID CHECK FUND INSTRUCTIONS

UNPAID CHECK FUND INSTRUCTIONS UNPAID CHECK FUND INSTRUCTIONS How to file a claim: If you are an individual filing a claim: Complete the claimant portion of the claim form to the best of your knowledge. The claim form must include each

More information

Iron Horse Acquisition Holding LLC 1345 Avenue of the Americas, 46 th Floor New York, New York 10105

Iron Horse Acquisition Holding LLC 1345 Avenue of the Americas, 46 th Floor New York, New York 10105 Iron Horse Acquisition Holding LLC 1345 Avenue of the Americas, 46 th Floor New York, New York 10105 Dear Former Shareholder of Florida East Coast Industries, Inc. As you are likely aware, on July 24,

More information

University of South Florida Request for Taxpayer Identification Number and Certification Substitute IRS Form W-9

University of South Florida Request for Taxpayer Identification Number and Certification Substitute IRS Form W-9 University of South Florida Request for Taxpayer Identification Number and Certification Substitute IRS Form W9 Name (as shown on your income tax return) Print or type See Specific Instructions on Instruction

More information

Request for Taxpayer Identification Number and Certification

Request for Taxpayer Identification Number and Certification Form W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification 1 Name (as shown on your income tax return). Name is required

More information

CONTRIBUTION AGREEMENT of INCROWD ALABAMA FUND I, LLC

CONTRIBUTION AGREEMENT of INCROWD ALABAMA FUND I, LLC CONTRIBUTION AGREEMENT of INCROWD ALABAMA FUND I, LLC INSTRUCTIONS TO INVESTORS EACH PROSPECTIVE INVESTOR IN INCROWD ALABAMA FUND I, LLC (THE COMPANY ) SHOULD EXAMINE THE SUITABILITY OF THIS TYPE OF INVESTMENT

More information

Computershare CIP. A Direct Stock Purchase and Dividend Reinvestment Plan

Computershare CIP. A Direct Stock Purchase and Dividend Reinvestment Plan Computershare CIP A Direct Stock Purchase and Dividend Reinvestment Plan This plan is sponsored and administered by Computershare Trust Company, N.A., not by any appointing issuer. Computershare provides

More information

Account Application. Step One Account Registration. Institutional Class Shares. Customer Identification Program. What this means for you:

Account Application. Step One Account Registration. Institutional Class Shares. Customer Identification Program. What this means for you: Account Application Institutional Class Shares This application can only be used for initial purchase of the Institutional Class shares of The Royce Funds listed on page 3. It cannot be used to open an

More information

Schwab One Account Application for Personal and Trust Accounts

Schwab One Account Application for Personal and Trust Accounts Investment Advisor ( IA ) Information (This portion to be completed by IA.) IA Firm Name (please print): IA Master Account Number: Service Team: Advisor Contact Information (if follow-up is required):

More information

SUBSCRIPTION AGREEMENT. of PACIFIC WEST MORTGAGE FUND, LLC A California limited liability company

SUBSCRIPTION AGREEMENT. of PACIFIC WEST MORTGAGE FUND, LLC A California limited liability company Investor/Member No.: SUBSCRIPTION AGREEMENT of PACIFIC WEST MORTGAGE FUND, LLC A California limited liability company Pursuant to this Subscription Agreement of Pacific West Mortgage Fund, LLC (the "LLC"),

More information

Stock Power Form for transferring shares, changing names, or adding a beneficiary

Stock Power Form for transferring shares, changing names, or adding a beneficiary ... Stock Power Form for transferring shares, changing names, or adding a beneficiary Section A: Current Owner Information A new form is needed for each account and company of stock for which you are transferring.

More information

Financial Advisor New Account Application

Financial Advisor New Account Application Financial Advisor New Account Application For Trusts, Partnerships, Corporations, Estates, or Other Entities Complete this application to establish an account for a trust, partnership, corporation, estate,

More information

Owner s name (First, M.I., Last) Required. Street (P.O. Box not acceptable except for APO/FPO) Required. Other Information (Suite, Attention, etc.

Owner s name (First, M.I., Last) Required. Street (P.O. Box not acceptable except for APO/FPO) Required. Other Information (Suite, Attention, etc. IRA Application (ADOPTION AGREEMENT) Baron Asset Fund Baron Fifth Avenue Growth Fund Baron Growth Fund Baron Partners Fund Baron Discovery Fund Baron Focused Growth Fund Baron International Growth Fund

More information

Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for Altria Group, Inc. Common Stock

Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for Altria Group, Inc. Common Stock Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for Altria Group, Inc. Common Stock This plan is sponsored and administered by Computershare Trust Company, N.A. Not

More information

Brokerage Account Application (Non-IRA)

Brokerage Account Application (Non-IRA) Brokerage Account Application (Non-IRA) One Beacon Street Boston, MA 02108-3102 (800) 822-2021 brownco.com For BrownCo Use Only: Account Number Instructions: Please complete in full and print clearly in

More information

Computershare Investment Plan

Computershare Investment Plan Computershare Investment Plan A Dividend Reinvestment Plan for Registered Shareholders of Abbott Laboratories Common Stock This plan is sponsored and administered by Computershare Trust Company, N.A. Not

More information

IMPORTANT TAX INFORMATION:

IMPORTANT TAX INFORMATION: Withdrawal Request For IRA and Non-Qualified Contracts John Hancock Annuities Introduction Instructions Use this form to request either a full surrender or a partial withdrawal from your nonqualified or

More information

Traditional, Roth, SEP-IRA, or SIMPLE IRA Application

Traditional, Roth, SEP-IRA, or SIMPLE IRA Application Traditional, Roth, SEP-IRA, or SIMPLE IRA Application A fund family of Everence Please call if you have any questions about filling out this application. (800) 977-2947 Send this application, and if applicable,

More information

Institutional Class Account Application

Institutional Class Account Application U.S. Global Investors Funds Institutional Class Account Application YOUR ORIGINAL SIGNATURE(S) IS(ARE) REQUIRED IN SECTION 9 Accounts must have a valid physical U.S. address and each registered owner(s)

More information

Computershare Investment Plan

Computershare Investment Plan Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for Frontier Communications Corporation Common Stock For investors in This plan is sponsored and administered by Computershare

More information

Individual Retirement Account (IRA) Application

Individual Retirement Account (IRA) Application PO Box 2237 Omaha, NE 68103-2237 Fax: 816-243-3765 ACCOUNT NUMBER Office Code Rep Code 1 Individual Retirement Account (IRA) Application Type of Account Please select only one. I want to establish a: A

More information

IRA Distribution Request Form

IRA Distribution Request Form Columbia Management Investment Services Corp. IRA Distribution Request Form Use this form when requesting a distribution from an Individual Retirement Account (IRA). Part 1 Depositor (investor) information:

More information

Computershare Investment Plan

Computershare Investment Plan Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for The Coca-Cola Company Common Stock For investors in This plan is sponsored and administered by Computershare Trust

More information

The Investor Services Program

The Investor Services Program The Investor Services Program A Direct Stock Purchase and Dividend Reinvestment Plan for International Business Machines Corporation Common Stock For investors in This plan is sponsored and administered

More information

Computershare Investment Plan

Computershare Investment Plan Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for Ford Motor Company Common Stock For investors in This plan is sponsored and administered by Computershare Trust

More information

INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT ADOPTION AGREEMENT

INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT ADOPTION AGREEMENT INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT ADOPTION AGREEMENT Please complete this application to establish a new Traditional IRA or Roth IRA. This application must be preceded or accompanied by a current

More information

FORM FOR SPONSORSHIP OR DONATION REQUEST SUBMISSION

FORM FOR SPONSORSHIP OR DONATION REQUEST SUBMISSION FORM FOR SPONSORSHIP OR DONATION REQUEST SUBMISSION TODAY S DATE: NAME OF ORGANIZATION: PERSON SUBMITTING REQUEST: NAME OF ORGANIZATION REP: EMAIL ADDRESS: STREET ADDRESS/P.O. BOX: _ TELEPHONE NUMBER(S):

More information

IRA APPLICATION STEP 1. IRA Type. Traditional IRA. Roth IRA SEP-IRA. Complete, sign, and mail to the above address

IRA APPLICATION STEP 1. IRA Type. Traditional IRA. Roth IRA SEP-IRA. Complete, sign, and mail to the above address Eventide Funds c/o Gemini Fund Services LLC PO Box 541150 Omaha, NE 68154 877-771-EVEN (3836) WWW.EVENTIDEFUNDS.COM IRA APPLICATION Complete, sign, and mail to the above address IMPORTANT Eventide Funds

More information

INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT ADOPTION AGREEMENT

INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT ADOPTION AGREEMENT INDIVIDUAL RETIREMENT CUSTODIAL ACCOUNT ADOPTION AGREEMENT Please complete this application to establish a new Traditional IRA or Roth IRA. This application must be preceded or accompanied by a current

More information

NOTICE OF AMENDMENT TO THE DIRECT STOCK PURCHASE AND DIVIDEND REINVESTMENT PLAN SPONSORED BY COMPUTERSHARE TRUST COMPANY, N.A.

NOTICE OF AMENDMENT TO THE DIRECT STOCK PURCHASE AND DIVIDEND REINVESTMENT PLAN SPONSORED BY COMPUTERSHARE TRUST COMPANY, N.A. NOTICE OF AMENDMENT TO THE DIRECT STOCK PURCHASE AND DIVIDEND REINVESTMENT PLAN SPONSORED BY COMPUTERSHARE TRUST COMPANY, N.A. (the Plan ) Computershare Trust Company, N.A. is pleased to inform you that

More information

Request for Change of Registration

Request for Change of Registration Request for Change of Registration To an Individual Account, Joint Account, Uniform Gifts/Transfers to Minors Act (UGMA/UTMA) Account, or Guardianship Account Complete this form to transfer ownership of

More information

Computershare Investment Plan

Computershare Investment Plan Computershare Investment Plan A Direct Stock Purchase and Dividend Reinvestment Plan for Harley-Davidson, Inc. Common Stock For investors in This plan is sponsored and administered by Computershare Trust

More information

Institutional Account Application

Institutional Account Application Institutional Account Application For Individuals, Joint Accounts, Uniform Gifts/Transfers to Minors Act (UGMA/UTMA) Accounts, Guardianships, Estates, Trusts, and Business Accounts wellsfargo.com/advantagefunds

More information

INVESTMENT ADVISORY AGREEMENT INSTRUCTIONS

INVESTMENT ADVISORY AGREEMENT INSTRUCTIONS INVESTMENT ADVISORY AGREEMENT INSTRUCTIONS Please find attached (or enclosed) the following documents: 1. Investment Advisory Agreement 2. Schedule A: Investment Management Fee Schedule 3. Schedule B:

More information

CONTACT ACCOUNTS PAYABLE FOR QUESTIONS (541) 885-1226

CONTACT ACCOUNTS PAYABLE FOR QUESTIONS (541) 885-1226 OREGON INSTITUTE OF TECHNOLOGY NEW VENDOR SETUP FORM Mail Attn: Accounts Payable, 3201 Campus Dr., Klamath Falls, OR 97601, or Fax (541) 885-1115 Oregon Tech Department (To be completed by Dept. Requester)

More information

HOOVER FINANCIAL ADVISORS, PC FINANCIAL PLANNING AND CONSULTING AGREEMENT

HOOVER FINANCIAL ADVISORS, PC FINANCIAL PLANNING AND CONSULTING AGREEMENT FINANCIAL PLANNING AND CONSULTING AGREEMENT This financial planning and/or consulting agreement ( Agreement ) made as of the day of, 2016 between the undersigned party, ( Client ), the Investment Advisory

More information

IVA Funds New IRA Account Application

IVA Funds New IRA Account Application PLEASE PRINT ALL ITEMS CLEARLY IVA Funds New IRA Account Application This form may be used to open a new Traditional IRA, Rollover IRA, Roth IRA, or SEP IRA in accordance with the Custodial Account Adoption

More information

IRA Beneficiary Election Form For assistance, please contact us at 1-800-243-1574 or visit our website at Virtus.com

IRA Beneficiary Election Form For assistance, please contact us at 1-800-243-1574 or visit our website at Virtus.com Virtus Investment Partners PO Box 9874 Providence, RI 02940-8074 IRA Beneficiary Election Form For assistance, please contact us at 1-800-243-1574 or visit our website at Virtus.com Important Information

More information

ACCOUNT APPLICATION P. O. BOX 701 Milwaukee WI 53201 800.421.4184 Fax 855.394.8958 www.eagleasset.com

ACCOUNT APPLICATION P. O. BOX 701 Milwaukee WI 53201 800.421.4184 Fax 855.394.8958 www.eagleasset.com ACCOUNT APPLICATION P. O. BOX 701 Milwaukee WI 53201 800.421.4184 Fax 855.394.8958 www.eagleasset.com IMPORTANT: YOU MUST COMPLETE ALL 5 PAGES AND ALL OWNERS MUST SIGN THIS APPLICATION. IF YOU ARE UPDATING

More information

Request For Proposal. Locum Tenens Psychiatric Coverage

Request For Proposal. Locum Tenens Psychiatric Coverage Request For Proposal Locum Tenens Psychiatric Coverage Heartland Behavioral Healthcare, an innovative multi-service behavioral healthcare organization located in Massillon, Ohio, is seeking to enter into

More information

New Account Application Advisor Class and Service Class

New Account Application Advisor Class and Service Class New Account Application Advisor Class and Service Class PNC Advantage Institutional Treasury Money Market Fund IMPORTANT INFORMATION PLEASE READ Please complete the investment selection and account information

More information

Terms & Conditions of Janney Montgomery Scott LLC Transfer on Death ( TOD ) Account Registration

Terms & Conditions of Janney Montgomery Scott LLC Transfer on Death ( TOD ) Account Registration Terms & Conditions of Janney Montgomery Scott LLC Transfer on Death ( TOD ) Account Registration Instructions: Carefully read the Terms & Conditions below and complete all applicable sections of the attached

More information

First Name Middle Initial Last Name Social Security/Tax ID No. (required)

First Name Middle Initial Last Name Social Security/Tax ID No. (required) PAGE 1 OF 5 Regular mail: Pax World Mutual Funds PO Box 55370 Boston MA 02205-5370 Overnight mail: Pax World Mutual Funds c/o BFDS 30 Dan Road, Suite #55370 Canton, MA 02021-2809 Telephone: 800.372.7827

More information

SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT

SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT Please complete this application to establish a new SIMPLE IRA. This application must be preceded or accompanied by a current Disclosure Statement and Custodial

More information

PRODUCER QUESTIONNAIRE

PRODUCER QUESTIONNAIRE PRODUCER QUESTIONNAIRE Agency Name: Main Address: Phone: Fax: Email: Website: (*Note: If multiple locations, please provide address, phone, etc., on attached Schedule A.) Tax Identification Number: (*Note:

More information

Change of Registration Joint Account Checklist

Change of Registration Joint Account Checklist Change of Registration Joint Account Checklist PO Box 55932 Boston, MA 02205-5932 800-240-4313 Use these forms to add or remove an owner(s) on a joint account or transfer a joint account to a new owner(s).

More information

STATE OF WYOMING WOLFS-109a Vendor Form

STATE OF WYOMING WOLFS-109a Vendor Form STATE OF WYOMING WOLFS-109a Vendor Form The State of Wyoming must have a properly completed form before payment will be made. PLEASE RETURN THIS FORM TO STATE AGENCY CONTACT VENDOR IS DOING BUSINESS WITH

More information

Name: Tribal Number:

Name: Tribal Number: Name: Tribal Number: Drum Group Name: Indicate: Northern Southern # of Members in group Name: Address: Phone no: / Email: Tribe/Tribal Affiliation: Lead Singer: #8: #1: #2: #3: #4: #5: #6: #7: #9: #10:

More information

SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT

SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT Please complete this application to establish a new SIMPLE IRA. This application must be preceded or accompanied by a current Disclosure Statement and Custodial Agreement. For Additional Copies or Assistance

More information

IRA Application. Class C and S Shares

IRA Application. Class C and S Shares IRA Application Class C and S Shares Instructions Use this form for IRA individual, custodial, trust,profit-sharing and pension plan accounts. Do not use this form for ICON Funds Class A accounts. For

More information

SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT

SIMPLE IRA CUSTODIAL ACCOUNT ADOPTION AGREEMENT Please complete this application to establish a new SIMPLE IRA. This application must be preceded or accompanied by a current Disclosure Statement and Custodial Agreement. For Additional Copies or Assistance

More information

EDISON INTERNATIONAL

EDISON INTERNATIONAL PROSPECTUS EDISON INTERNATIONAL Dividend Reinvestment and Direct Stock Purchase Plan Our Dividend Reinvestment and Direct Stock Purchase Plan (the Plan) provides you an economical and convenient method

More information

INSTITUTIONAL FUND CLASS I SHARES NEW ACCOUNT APPLICATION

INSTITUTIONAL FUND CLASS I SHARES NEW ACCOUNT APPLICATION INSTITUTIONAL FUND CLASS I SHARES NEW ACCOUNT APPLICATION (Please Print in Black Ink) For assistance in completing this application, please call your financial advisor or a Virtus Mutual Fund Services

More information

A. Current account owner(s) Complete section 2, you may need to obtain a Medallion Guarantee. B. New account owner(s) Complete sections 3 through 10.

A. Current account owner(s) Complete section 2, you may need to obtain a Medallion Guarantee. B. New account owner(s) Complete sections 3 through 10. Non-Retirement Accounts N 1 Instructions Overview FOR ASSISTANCE with this form, call Shareholder Services at (800) 662-0201, or the Timothy Plan at (800) 846-7526. SIGNATURE GUARANTEE: For gifts over

More information

Transfer of Ownership At-A-Glance

Transfer of Ownership At-A-Glance AMERICAN STOCK Transfer & Trust Company, LLC Transfer of Ownership At-A-Glance This At-A-Glance booklet will guide you through the specific requirements for transferring stock ownership. Required documents

More information

Enclosed are copies of the Synchrony Bank Account Agreement and Fee Schedule please retain them for future reference.

Enclosed are copies of the Synchrony Bank Account Agreement and Fee Schedule please retain them for future reference. Dear Valued Customer, Thank you for your interest in establishing a business account with Synchrony Bank. Establishing an account is convenient and easy to manage. We look forward to bringing you a new

More information

2 Provide account holder information (Please attach necessary documents.)

2 Provide account holder information (Please attach necessary documents.) Brokerage Account 1 Specify type of account ownership (Please attach necessary documents.) ( Minimum opening balance of $1,000 in cash and/or securities is required.) Select the type of account ownership:

More information

Certificate for Trust or Entity Ownership

Certificate for Trust or Entity Ownership Instructions Certificate for Trust or Entity Ownership Complete when applying for a nonqualified contract with a trust or entity as the owner or for ownership changes. Examples include contracts owned

More information

Verizon Communications

Verizon Communications A Direct Stock Purchase and Share Ownership Plan for Common Stock, $.10 par value per share, of Verizon Communications Inc. Verizon Communications Direct Invest Purchase Verizon shares conveniently. Build

More information

The account owner is the person who establishes and controls the account. Account Owner s First Name M.I. Last Name

The account owner is the person who establishes and controls the account. Account Owner s First Name M.I. Last Name The State Farm College Savings Plan Account Application Please complete this application to establish your State Farm College Savings Plan account. IMPORTANT INFORMATION ABOUT OPENING AN ACCOUNT: To help

More information

Other You must complete a W-8BEN form. Please call the phone number above to obtain a form.

Other You must complete a W-8BEN form. Please call the phone number above to obtain a form. Joint - Custodial - Trust - Will be presumed to be joint tenants with rights of survivorship unless restricted by applicable state law or otherwise indicated. Aminor is the beneficial owner of the account

More information

Investment Advisor Firm (Agent) and Primary Contact: Firm Name: Primary Contact:

Investment Advisor Firm (Agent) and Primary Contact: Firm Name: Primary Contact: INVESTMENT ADVISOR Beneficiary IRA Account Application Account # Advisor # Case # Investment Advisor Firm (Agent) and Primary Contact: Firm Name: Primary Contact: 1 2 DECEDENT S RETIREMENT ACCOUNT INFORMATION

More information

Before You Begin. INSTRUCTIONS Trading Authority Form

Before You Begin. INSTRUCTIONS Trading Authority Form INSTRUCTIONS Trading Authority Form Use this form to: grant trading authority to an authorized agent (someone who is not an account owner) remove or replace authorized agents update information on an authorized

More information

DESCRIPTION OF THE PLAN

DESCRIPTION OF THE PLAN DESCRIPTION OF THE PLAN PURPOSE 1. What is the purpose of the Plan? The purpose of the Plan is to provide eligible record owners of common stock of the Company with a simple and convenient means of investing

More information

TAX ASPECTS OF MUTUAL FUND INVESTING

TAX ASPECTS OF MUTUAL FUND INVESTING Tax Guide for 2015 TAX ASPECTS OF MUTUAL FUND INVESTING INTRODUCTION I. Mutual Fund Distributions A. Distributions From All Mutual Funds 1. Net Investment Income and Short-Term Capital Gain Distributions

More information

New Account Application Please do not use this application for IRA s

New Account Application Please do not use this application for IRA s New Account Application Please do not use this application for IRA s In compliance with the USA PATRIOT Act, all financial institutions (including mutual funds) are required to obtain, verify and record

More information

Bank. Account Number. Employer. Business Address. E-Mail Address. Liquid Net Worth

Bank. Account Number. Employer. Business Address. E-Mail Address. Liquid Net Worth DOC0105 Ameriprise Financial Services, Inc. 70100 Ameriprise Financial Center Minneapolis, MN 55474 Ameriprise Brokerage Individual Retirement Account (IRA) Application Part 1 Account Owner Details Account

More information

ACCOUNT APPLICATION FEDERAL CUSTOMER IDENTIFICATION REGULATIONS 1. ACCOUNT REGISTRATION (PLEASE INDICATE ACCOUNT TYPE)

ACCOUNT APPLICATION FEDERAL CUSTOMER IDENTIFICATION REGULATIONS 1. ACCOUNT REGISTRATION (PLEASE INDICATE ACCOUNT TYPE) Please return this completed application to: The Lazard Funds, Inc. P.O. Box 8514 Boston, MA 02266-8514 For assistance please call: (800) 986-3455 ACCOUNT APPLICATION Use this form to purchase Lazard mutual

More information

Inheriting an IRA Individual Beneficiary Checklist

Inheriting an IRA Individual Beneficiary Checklist Inheriting an IRA Individual Beneficiary Checklist PO Box 55932 Boston, MA 02205-5932 800-240-4313 Re-registration Requirements Completed Janus IRA Beneficiary Claim Form Individual Beneficiary Certified

More information

BUSINESS ACCOUNT AGREEMENT

BUSINESS ACCOUNT AGREEMENT BUSINESS ACCOUNT AGREEMENT OWNERSHIP OF ACCOUNT SOLE PROPRIETORSHIP CORPORATION NOT FOR PROFIT CORPORATION FOR PROFIT PARTNERSHIP LIMITED LIABILITY CO. DATE OPENED OPENED BY INITIAL AMOUNT $ FORM: CASH

More information